New hope for elder mental health research.

Occasionally, even the most experienced Washington observers must eat their words. Last year, I detailed in this column (October 2003, p. 8) why tripling the federal budget for the National Institutes of Health (NIH) has not produced new research that nursing homes and other long-term care providers can use. Most of that column remains valid; NIH's spectacular growth under both the Clinton and the George W. Bush administrations is unlikely to generate much benefit for SNFs' quality of care.

In February, however, the National Institute of Mental Health (NIMH) decided to devote a portion of its rapidly growing budget to specifically help older Americans. NIMH responded to pressure from the American Psychological Association's Office on Aging, the American Association for Geriatric Psychiatry, and other advocacy organizations by reestablishing a Geriatric Treatment and Preventive Intervention Research Branch (GTPIRB). NIMH had maintained such a branch during the 1980s but allowed it to be merged with a general "adult mental health" branch ten years ago.

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Support for reestablishing an NIMH branch devoted to aging was bolstered by an internal work group report, which found that in 2002, NIMH provided four times the grant funding ($358 million) to child research as to aging research ($90 million). The NIMH work group's final report, Mental Health for a Lifetime: Research for the Mental Health Needs of Older Americans, found that few mental health researchers specialize in research on elderly patients, despite new information that many mental health problems associated with aging are preventable. According to Barry Lebowitz, PhD, the new GTPIRB director, "A few years ago, you didn't use the terms 'preventive' and 'geriatrics' in the same sentence."

The NIMH work group found that research grant applications proposing to study geriatric treatment and prevention of mental disorders other than Alzheimer's disease tend to score higher at NIMH than grant applications for other topics. The dearth of research, according to the work group, stems almost entirely from the lack of applications. To counter this problem, the work group recommended that NIMH actively recruit psychiatrists and psychologists to study the mental health needs of older Americans and create a position of Associate Director for Aging. Instead, NIMH split its Adult and Geriatric branch into two branches: the new aging branch and an adult-specific branch.

The GTPIRB will support a program of research, research training, and career development focusing on treatment, prevention, and rehabilitation of mental disorders in older people. The branch's program focus is broad and inclusive with respect to the type of patients, the severity of disorders, and the variety of community and institutional settings in which treatment is provided. The branch proposes to study all mental disorders, including Alzheimer's disease and related dementias, suicide, eating disorders, sleep disorders, and disorders related to the menstrual cycle.

Dr. Lebowitz explains that the new branch will present opportunities to conduct research on an array of topics, including chronic stress, depression, and brain-hormone interactions as they affect older populations. The research program's primary focus is the expansion of traditional treatment research ("efficacy studies") to include research of more practical and public health relevance ("effectiveness studies"). Interventions studied will include pharmacologic approaches (individual drugs and combinations of drugs), and behavioral and psychotherapeutic approaches (e.g., cognitive therapy).

The GTPIRB's Geriatric Psychosocial Program, headed by George T. Niederehe, PhD, will generate research that will be especially interesting to the nursing home field. Dr. Niederehe's responsibility includes grants for the development and application of new psychotherapeutic, behavioral, and psychosocial treatments, and assessment of standardized approaches to treatment based on treatment manuals.

Dr. Lebowitz points out that several NIMH-funded researchers already are known for focusing their attention on nursing home care. Virtually all of them are "external" researchers who are attached to academic institutions and receive research grants for conducting their work in long-term care settings. Ira Katz, MD, PhD, for example, is director of the Section of Geriatric Psychiatry at the University of Pennsylvania and has received grants to study the most effective approaches to reducing the severity of depression in nursing home residents. Early results of his research are in a chapter on nursing home care in Evidence-Based Care for Patients With Dementia (Oxford University Press, in press).

Another NIMH-funded researcher known for collaboration with nursing homes is Bruce Pollock, MD, PhD, director of the Department of Psychiatry's Geriatric Psychopharmacology Program at the University of Pittsburgh. Dr. Pollock's research has focused on how the aging process changes the effectiveness of antidepressant medications. According to him, SNFs are in a difficult position because the interaction of antidepressants with other medications taken by residents can increase the risk of side effects, but undermedicating contributes to the relatively high incidence of clinical depression in the nursing home setting. Dr. Pollock also notes that nonpharmacologic intervention, such as making sure nursing home residents can choose an activity they're interested in during the week, can also help with depression.

According to Dr. Lebowitz, the refocusing of efforts recommended by the NIMH work group should include more support for research on the psychological effects of Alzheimer's. These include psychosis, hallucinations, sleep disturbances, and anxiety, in addition to the more familiar memory problems and disorientation. He also believes significant opportunities exist for the rehabilitation sections of nursing homes to serve as settings for practical studies on prevention of depression after a stroke. Dr. Lebowitz says that the branch already is planning to fund a study of preventive care in assisted living facilities, but he cannot release details until the grant award is formally announced to the researchers.

The funds involved in the reestablishment of NIMH's GTPIRB are only a tiny fraction of NIH spending. It involves millions of dollars--small change compared with the billions of dollars discussed in budget cuts and increases for Medicaid and Medicare. However, it is impossible to listen to the infectious excitement in the voices of these researchers and NIMH officials without feeling that their work has the possibility of making a real difference in the lives of nursing home residents. Hopefully, SNFs will take advantage of this enthusiasm by linking with academic mental health researchers to apply for NIMH grants.

In this case, at least, having to eat my words left a good aftertaste.

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